Are you satisfied working as a specialist in a New Zealand public hospital?

Job satisfaction among doctors has been in the news recently with a fall in job satisfaction and pay reported in the United States.1 This week’s issue of the Journal includes a timely article by Ashton et al entitled Sources of satisfaction and dissatisfaction among specialists within the public and private health sectors.2 Not surprisingly the authors find that overall levels of job satisfaction were higher in the private sector than the public sector and that levels of dissatisfaction were lower there as well.

The authors go on to report that although specialists responding to their questionnaire valued the public system for its opportunities for further education and professional development they were more satisfied working in the private system.

The key sources of dissatisfaction with the public system are workload pressures, mentally demanding work and managerial interference—while in the private sector specialists value the opportunity to work independently and apply their own ideas in the workplace.

Income alone is not a factor in the satisfaction of private practice, although in reality it must have some role with some proceduralists earning as much as 4–5 times (or more) their public salary in the private sector. This gap is much bigger in some cases when compared with opportunities that exist for some at the nearby Australian doctor market.

Job satisfaction and work-life balance are discussed as non-medical media as being important today. So the concept that someone would do a job that is less than maximally satisfying is considered odd. As a result, after reading Ashton et al’s paper, one could easily come to the conclusion that one should leave the public sector and move entirely into the private sector, where one would find job satisfaction and “happiness” as we would have more control and less managerial interference (and more pay)—or is this a delusion?

The public sector in New Zealand employs over 7000 doctors FTE (full time equivalent), most of whom are junior doctors (resident medical officers: RMOs). The study by Ashton et al was focused on specialist who in the public sector are called senior doctors (senior medical officers: SMOs) who are much fewer in number and have overall responsibility for patient care.

Questionnaires were sent to 1983 specialists from 28 specialties, not all of whom work in the public sector. 943 doctors returned the questionnaire of which 473 worked in both the public and private sector, while 306 worked in the public sector alone and 130 in the private sector alone. The 47% return rate is good for such studies, however the results are arguably open to biases as those returning the question may be the dissatisfied ones. It should also be acknowledged that the absolute scores for doctors’ satisfaction appear to be very good.

To clarify the facts on what creates job satisfaction I thought I should “research” the concept of ‘job satisfaction’ and as such went as the ‘Google’ search engine as usual. A few surprising facts came to light such from sources such as “Wikipedia” where the authors state the following:3

“...job satisfaction is simply how content an individual is with his or her job.”

“Job satisfaction is thought by many to be important because it boosts work performance but and also because it increases our quality of life. However one common research finding is that job satisfaction is correlated with life satisfaction. This correlation is reciprocal, meaning people who are satisfied with life tend to be satisfied with their job and people who are satisfied with their job tend to be satisfied with life.

“An important finding for organizations is that job satisfaction has a rather tenuous correlation to productivity on the job. This is a vital piece of information to researchers and businesses, as the idea that satisfaction and job performance are directly related to one another is often cited in the media and in some non-academic management literature. A recent meta-analysis found surprisingly low correlations between job satisfaction and performance. Further, the meta-analysis found that the relationship between satisfaction and performance can be moderated by job complexity, such that for high-complexity jobs the correlation between satisfaction and performance is higher than for jobs of low to moderate complexity.

There appears to be many theories about what creates job satisfaction. Overall, however, most make a distinction between affective job satisfaction and cognitive job satisfaction.3

Affective job satisfaction is the extent of pleasurable emotional feelings individuals have about their jobs overall, and is different to cognitive job satisfaction which is the extent of individuals’ satisfaction with particular facets of their jobs, such as pay, pension arrangements, working hours, and numerous other similar aspects of their jobs.

There are other theories of course (3) as well such as the “Equity theory”(3) where it is argued that comparative fairness is important between employees (e.g. people are satisfied if people are pad the same for the same outputs); there is the “discrepancy theory” (3), which claims people work to avoid anxiety and dejection; and it is the gap between what they do and what they are expected to do that creates dissatisfaction.

There is also the “Frederick Herzberg’s two-factor theory (also known as motivator hygiene theory)”(3) so called as it describes “motivating factors” which are intrinsic to the job and which make people feel good about what they do and what they call “hygiene factors” such as pay and company policies and so on.

Trying to put all this together I am left with the conclusions from reading the heterogenic Internet Googlings that there are three aspects overall that appear important in job satisfaction, these are:

The individual factors that we all bring to a job (partially genetic and partially environmental—home life, etc.). As we all know, some of us are happy people and easier to satisfy than others.

There is the job itself; some jobs give us the sense of purpose and achievement (i.e. we feel good about doing them).

Then there is the work environment itself. This, as suggested above, can be subdivided into two broad areas. This is (a) the work “fixed” environment or “cognitive” i.e. having an office, what we are paid, availability of parking, polices about stuff etc, and (b) the “ adjustable” environment such as communication with managers, relationships with staff, and what is called strategic employee factors.

If we accept that we want as doctors to have our best job satisfaction, but wish to stay in the public sector, then the aspects that appear to be adjustable are outlined in the paper by Ashton et al.

The public sector can’t match the incomes of the private sector, any more than I expect management can stop interfering, so I would suggest that factors that might be considered in to retain SMOs are:6

Perception of fair pay—For a doctor to be satisfied, their pay should be fair and equitable.

Achievement—Doctors need to feel more satisfied with their job if they’ve achieved something.

Feedback—Most feedback we get is generally negative such as unmet waitlist times, patients needing to be seen in clinics that are already full, patients wanting surgery sooner than we can provide, complaints (hospitals, HDC, and letter to ACC), and so on. The positive feedback we get is generally from patients, which is part of the reason why we like seeing patients.

Complexity and variety—To be satisfied, most of us need to be challenged a little and they need some variety in the tasks they carry out.

Control—The more control we perceive we have in carrying out our jobs, the more satisfaction we experience.

Organisational support—Doctors want to know that their employer organisation (DHB, university etc) cares about them.

It is most likely that the DHBs are well aware of the importance of retaining SMOs, as staff are their most valuable asset, and they are generally cheaper to retain than replace.